• LA OWCA Second Injury Board Knowledge Questionnaire

    The following questionnaire should only be completed by individuals that have been hired for employment. Your employer may ask that you complete this questionnaire following your initial hire and periodically thereafter. The questionnaire may be used in the establishment of prior knowledge for the purpose of obtaining Second Injury Fund Relief from the Second Injury Board. The Second Injury Board may reimburse your employer for workers' compensation claims that meet criteria should you become injured on the job. This reimbursement in no way affects the benefits owed to you by your employer or their insurance company under the Louisiana Workers' Compensation Act, La. R.S. 23:1021-1361.

  • FAILURE TO ANSWER TRUTHFULLY AND/OR CORRECTLY TO ANY OF THE QUESTIONS ON THIS FORM MAY RESULT IN A FORGEITURE OF YOUR WORKERS COMPENSATION BENEFITS UNDER LA R.S. 23:1208.1.

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  • Please place a check in the appropriate box next to each medical condition listed below. Each illness or condition requires a YES (Y) or a NO (N) answer. For all conditions that you check yes, write a brief explanation on the Explanation Page.
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  • EXPLANATION PAGE

    Please use the space below to explain the illness and/or condition that you checked a Yes (Y) or any other medical conditions that may not be listed on this form.
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  • Please answer the following questions:
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  • Should be Empty: